Dental Benefit Companies Respond to the Oral-Systemic Relationship

Dr. Keith Libou

By Dr. Keith Libou

There is a growing body of information supporting the relationship between oral health and total patient wellness.  While a direct causal relationship has not yet been established, periodontal disease is believed to play a role in diabetes, cardiovascular disease, cerebrovascular disease, low birth weight babies, rheumatoid arthritis, and other systemic conditions.

The Two Goals Regarding Periodontal Health

The dental profession has long had two primary goals regarding periodontal health. The first goal is to prevent periodontal disease in the first place!  Fortunately dental benefits typically provide preventive and diagnostic coverage designed to encourage patients to obtain preventive care.

The second goal is to stop the progression of periodontal disease in patients diagnosed with periodontitis.  Dentists commonly recommend periodontal maintenance visits three to four times annually following scaling and root planing (along with excellent patient home care) to keep periodontal disease from progressing.

Since most dental benefit programs cover two dental cleanings a year in any combination (either prophylaxis or periodontal maintenance), some patients with periodontal disease may not accept more than two periodontal maintenance procedures annually because they want to avoid out-of-pocket costs.  This can lead to increased inflammation as their periodontal disease becomes active, and inflammation is one of the mechanisms believed to be involved in the progression of various systemic illnesses and events.

As the understanding about the relationship between oral and systemic health continues to develop, some dental benefit companies are exploring new ways to support overall patient health. Delta Dental of New Jersey, for instance, offers the option for eligible groups to enhance benefits for patients with periodontal disease.  Simply stated, if a patient with the Oral Health Enhancement benefit option has periodontal disease (and this is properly  demonstrated to Delta Dental), the patient’s dental benefits are increased to allow up to two additional periodontal maintenance visits or routine cleanings in a benefit year. 

Recognizing Patients at Risk for Systemic Conditions

Dentists are also taking on a greater role in recognizing patients at risk for various systemic conditions. The New Jersey State Board of Dentistry recently announced that “it is within the scope of practice of dentistry to administer blood sugar testing protocols in the dental office.” After the New Jersey Board of Dentistry issued its statement on dentists administering in-office blood sugar testing, Delta Dental of New Jersey developed an innovative pilot program that compensates dentists in the program for performing in-office HBA1c testing on patients with risk factors for type II diabetes, a program Delta Dental will likely expand in the future.

One of the most important trends affecting the dental profession in decades is the critical relationship between oral and system health. We are responding to support dentists as they take on an ever-larger role in identifying at-risk patients. We offer benefits programs that promote wellness for everyone—and additional benefits options for those with special oral health needs. Together, dentists and dental benefits providers help make a positive difference in the health and wellness of every patient and member.

About the Author: Dr. Keith Libou is Chief Clinical Officer at Delta Dental of New Jersey.

Delta Dental of New Jersey is an Endorsed Business Associate of the New Jersey Dental Association.

Toothbrushes for Ghana

Dr. Vaziri

By Dr. Mariam Vaziri

Dr. Vaziri is a frequent contributor on LinkedIn and is pleased to share this recent post with our readers. Dr. Vaziri is a general dentist, practicing in Summit and a member of the NJDA and the NJ Academy of General Dentistry.

What’s on your top 10 priorities list? Does it start with finances and career–and end with family and friends? Is there a long overdue girls trip or family getaways somewhere wedged in between the “important stuff? How about a class reunion? Or maybe addressing the peeling ceiling paint over the bathroom sink? But take a closer look. Is there any space on this list allotted for your health? Do you tend to put that on a separate list? Or worse, not on a list at all?

In the days of rush-rushproduceearn–we tend to neglect our personal health care. Whether it be scheduling a yearly physical, following up on that intermittent shoulder pain or one’s dental health–dental journals and the Mayo Clinic agree: “oral health is a window to one’s overall health.”

Now imagine if you were denied access to the basic tools that ensured your dental hygiene. Like toothpaste and a toothbrush.  What would your life be life without having these items? It’s not something that we in the U.S. think about often. But when we are reminded of the conveniences and entitlements that we are afforded, it’s a true gift.

Recently, a long time patient of mine, a 1st generation Ghanaian American, reminded me of this very reality. She was in for a cleaning before her annual family visit back to Ghana. We got to talking about the possible travel hiccups and restrictions imposed of late. At the end of her visit, I gave her the usual travel toothpaste and toothbrush gift bag. This prompted a very thoughtful and poignant response. She shared with me how in the U.S., these dental hygiene tools are readily available to all and in this case, free. But in Ghana, there are many who don’t have access and go without.

How many times have you chosen to go to bed after a meal and a long day, skipping the trip to the bathroom to brush (and floss!) your teeth? Taking it a step further, imagine being denied a toothbrush and toothpaste for days or weeks… I know most of you would be reeling from the grimy plaque build up after several hours, let alone days.

After she shared this emotional and thought provoking perspective, I thought about what I could do.  I realized instead of feeling helpless and guilty, I could do something positive. Before she left Summit Smiles, we made sure she was laiden with dozens of toothbrushes and toothpaste to take on her journey.

Moving forward, I’m approaching my dental mantra, said incessantly to all my patients, “Brush and floss twice a day,” with new vigor! Be grateful, be compassionate–brush and floss twice daily, because it’s a luxury that we have–that is not afforded to all…

Keep smiling, keep brushing & happy chewing! 😉

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NJDA’s Career Center is Having a Sale!

Use Promo Code SUMMER17 now through August 31 to receive a 25% discount on ads placed on the NJDA Career Center site.

Looking for a job? Dental professionals will find quality positions plus tips on how to land the perfect job.  Visit the Career Center today!

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Caveat Venditor – Let the Seller Beware Dr. Joan Monaco

As small business owners you have the right to set you own fees.  Unless you decline to participate with any insurer, you’re also caught up in the minutiae of contracts.  Or should be.  Because every contract you sign is an obligation to your patient and the company that pays their benefits.  Unless you read carefully, you may misunderstand the terms of an agreement or miss them altogether. Throw in coordination of benefits and coding and it’s easy to see where a practice might become entangled in a managerial mess.

So, back to setting fees.  You set your fees, hang your shingle and accept patients who agree to your fees.  Simple enough if the patient has no insurance at all.  Coming into the patient-doctor relationship, you will have told that patient the terms of your payment plan and they will have signed an agreement to pay according to the terms set forth.

The next patient through your door may have dental insurance, but you do not participate in the plan.  There are two options.  After making it clear to the patient that you don’t accept their plan, they may pay for services rendered and then submit for reimbursement out-of-network. Or, as a courtesy, you may submit for them, accept the amount reimbursed by the plan and bill the patient the difference.

The next patient through the door has insurance and it’s a plan you participate with. You perform a procedure and are reimbursed at an agreed upon rate. Can you collect the difference between your fee-for-service rate and the insurance rate?  No, you cannot charge the difference. The contract stipulates that the dentist cannot collect more than the negotiated fee. If they were reimbursed at the “negotiated fee”…then it ends there. If the insurance carrier reimburses a percentage (say 50%) then the dentist can charge the difference up to the negotiated fee.

The next patient has an insurance plan that you participate in. Your office policy is that if a patient loses coverage, they are liable for the fee-for-service rate, even if you are in mid-procedure. The patient is given a consent form outlining your policy but is hesitant to sign. What if she loses coverage during the procedure and can’t pay?  A potential patient, even if given a treatment plan, is not obligated to agree to the policy and you are not obligated to accept that patient if she will not agree to your terms.  Hopefully, you’ll part amicably, and move on to the next patient scenario.

The next patient through your door is in a similar situation.  He has insurance, accepts your terms and begins treatment, only to lose coverage during the process of having his restoration completed.  Your written policy, which he signed, specifies that he is liable for payment in full at your set rate.

This is a dilemma not only for the patient, but possibly for you as well. Legally, the patient is bound by the terms agreed to. You may feel a deal is a deal and the patient should pay in full. Or, you may decide that losing a patient is not worth the cost and you might continue treatment and accept payment from the patient at the insurer’s agreed upon rate.

Do you want to generate a “bad will” situation? According to some studies, a dissatisfied customer (in this case your patient) will share his bad experience more than five times, while a satisfied customer will share a positive experience far fewer times. 

Bottom line: Just like setting your fee schedule, the decision to waive or discount for a patient is yours as well.  A savvy business person will remember caveat venditor – let the seller beware.

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HIPAA Risk Assessment – Document, Document, Document! by Dr. Joan Monaco

HIPAA – Is your Compliance Program Intact?

The ADA Guide to HIPAA Compliance is a 3-inch binder loaded with fill-in-the-blank templates and information that is overwhelming to the average dental office. Although it is a good starting point for some and a valuable resource for others, the task of interpreting, translating and implementing it are monumental.

Having a manual with templates filled in doesn’t mean you are HIPAA compliant. While 100-percent compliance probably isn’t realistic, it seems HIPAA auditors are looking for “visibly demonstrable evidence” or VDE.  Making a good effort and documenting that effort can go a long way toward decreasing what could potentially be well more than $1.5 million in fines.

You or your staff must take time to review your current HIPAA policies, procedures and manuals. Incorporate the recent changes and make adjustments or modifications to include the new, enhanced privacy protections the Department of Health and Human Services recently updated with the Omnibus Rules.

HIPAA’s final Omnibus Rule includes new rights and strengthens the government’s ability to enforce the law.

With respect to Notice of Privacy Practices, one change is to include a patient’s right to restrict disclosures to insurers if services were paid in full, as well as a patient’s right to receive an electronic copy of electronic PHI.  My suggestion is to review your provider contracts with respect to this. A patient may ask you not to submit a claim which could be in direct contradiction to your participating provider agreement, that may dictate you submit a claim for any service provided to the patient covered, non-covered or even when the patient has exceeded their maximum allowance for the year.

The updates also expanded the requirements of business associates. Any non-employee that receives, maintains, transmits or creates PHI is considered a business associate. That should include IT professionals, software companies and vendors, accountants, bookkeepers, training companies, consultants, etc. Virtually anyone that has access to the practice’s PHI may be considered a business associate.  For example, the NJDA has signed a Business Associate Agreement in which NJDA agrees to safeguard protected health information presented by any member or member practice to the Association in the course of business.

 “According to one resource, 30-70% of security and privacy breaches involve a business associate.”

In the past, practices simply obtained a Business Associate Agreement (BAA) from their associates with the understanding that the associate safeguarded PHI. These business (non-employees) are held to the same standard as covered entities (dental practices), including the risk of penalties and fines. Do you have confidence in your business associates? Do you have an updated Business Associate Agreement on file?  If you do, have you verified that the agreement does not disclaim responsibility?

Your BAA must identify if the associate subcontracts with other individuals or groups. So for example, if your office contracts with an IT professional and the IT professional subcontracts a computer technician and a breach occurs, who is responsible? There is a snowball effect in determining which group is responsible and accountable for fines and penalties. It would probably be wise to ask if the business associate carries adequate liability insurance and perhaps even ask for their Security Risk Management Plan. (By the way, your office should have one as well!)

Security Risk Assessment

HIPAA’s general security rule addresses the confidentiality, integrity, and availability of electronic PHI. Risk assessments should be accurate and thorough. They should be updated. Recommendations for conducting risk assessments are available through the National Institute of Standards and Technology (NIST).

Identify your risks and prepare a Risk Management Plan. You want to be sure to maintain your privacy policy, your security policy and you want to make sure you have a contingency plan and back-up procedures. It can be overwhelming, so create an action plan that prioritizes what needs to be addressed first. This should be based on risk. The higher the level of risk, the higher priority it should be in your plan of action.

A suggested starting point is to identify your contacts (business associates) and any individuals that are authorized to make decisions.  This can be you — the practice owner — your staff or privacy/security officer, your office manager/practice administrator, and IT contacts, perhaps your healthcare attorney and of course your State Dental Association. Next, identify and categorize information systems. You can’t secure information if you are not sure where it is saved. Start with any electronic devices you use in the office; the file server, workstations, external hard drives, flash drives, copiers, scanners, backup tapes, DVDs, and so forth. Any outdated or obsolete information stored on hard drives, outdated DVD’s, CD –Roms, etc., should be destroyed. Identify realistic threats and potential vulnerabilities. This could be human (theft, fraud, inadvertent data entry), environmental (floods, tornadoes, storms), technical, and non-technical threats. If you store this data offsite and/or use encryption you can minimize these risks. Again, whatever you do – document, document, document. Establish a work procedure and provide training for the entire workforce. Create and implement strong security policies such as no one shares log-ins and passwords.

Employees must be informed that the practice protects patients’ privacy; however, employee workstations and portable devices are subject to view, such as the systems audit trails.  If the practice issues mobile phones, lap tops or tablets,  implement a remote wipe utility to protect the PHI stored on the device, such as emails, texts, and photos, in the event the device is stolen or lost.

Your documentation needs to be thorough. Although employees must understand that security infractions result in discipline and possible termination of employment, you still need to develop and implement a sanction policy to formally address system misuse, abuse, and fraudulent activity. Again, document, document, document! Determine how your practice deactivates log-ins and passwords when an individual’s employment is terminated, regardless if termination is voluntary or involuntary. Include the topic of remote access and how such access is immediately deactivated when an employee/provider ceases employment, and again document it!  Another suggestion, if your office uses a file server, physically safeguard that equipment.  Some practices secure the file server to the floor with brackets; others use a locked file server closet or some other method of protecting the server from theft.  Ask how you may encrypt the server when it is at rest. All this information needs to go into your HIPAA manual. If there is no documentation, then in the eyes of an auditor, it doesn’t exist.

Other physical safeguards might include an alarm system, secured windows, and prevention of unauthorized entry through a back door. If you practice in a professional building, make certain the dropped ceiling does not risk unauthorized access. If you can’t remedy that, document that you know it exists and propose a resolution even if it is unrealistic. Remember anyone who audits your practice is looking for VDE (visibly demonstrable evidence). Show you recognize the threat, propose a solution.

On the technical side of compliance, keep in mind that as of April, 2014, Windows no longer supports XP. Consult with your IT professional to find out if you are affected by this change.

Enable automatic logoff features. Find out if testing is necessary to ensure that the authentication system is working as prescribed. Encrypt emails that contain PHI. If emails are not encrypted and the patient requests the PHI via email, make sure they understand that there is a level of risk during transmission.  Disclosure is very important. It allows the patient to make a decision based on the risks. Prepare in advance how the practice will handle a security incident, and again, document, document, document! This policy should be included in your breach notification process.

A breach is an “impermissible use or disclosure of PHI unless there is a low probability that the data has been compromised.”   So, essentially the Omnibus Rule removed the “harm standard” in defining a reportable breach. This means the assessment is no longer based on harm to the patient or individual, but whether the information was compromised. Secured PHI is rendered unusable, unreadable, or indecipherable to unauthorized persons through the use of a technology or methodology such as encryption or destruction of data.

Numerous security experts reveal that the weak link in the HIPAA Compliance arena is a lack of a security risk assessment and a corresponding risk management plan.

As you re-evaluate your HIPAA Compliance Program and make appropriate adjustments and modifications, you will have a more realistic understanding of how secure or vulnerable your practice really is. Repeat the Risk Assessment periodically and make the needed modifications as needed. Be sure to document everything and review NJDA Monday Morning Emails for updates.

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What if a Needlestick Incident Occurs in My Office? by Dr. Joan Monaco

When an employee is exposed to a possible bloodborne pathogen via needlestick, follow these steps to assure your employee’s well-being and your compliance with OSHA and NJ State Board of Dentistry regulations.

Steps to Take After Exposure

  • Document the incident in your Sharps Injury Log (sample available at
  • Refer the affected employee to a health care provider. You may refer to the employee’s primary care physician if you’d like.
  • As the employer, you are financially responsible for the cost of the following:
    • Testing of the exposed employee
    • Notification of test results
    • Counseling
    • Post-exposure prophylaxis, if needed
    • Evaluation of reported illness
    • If the source of the needlestick is known, you should also provide the patient’s medical history to the health care provider handling your employee’s case.
    • Your financial responsibility to the employee ends here.
  • Send the written opinion of the health care provider to the employee within 15 days of the completed evaluation.
    • Document that the employee was informed of results and the need for any follow-up.

OSHA Reporting

NJ State Board of Dentistry Reporting

  • Per NJ State Board of Dentistry regulations, you must keep confidential records of exposure incidents for at least the duration of employment plus 30 years. This means if you close your practice, you must notify the State Board of the location where you are storing employee records.
Need stick web viewing
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New Kid on the Block – Dr. Dena Constandelis

Editor’s Note – This article originally appeared in the Journal of the NJ Dental Association. Dr. Constandelis continues to pursue leadership in organized dentistry in the Passaic County Dental Society and concluded a year as president of PCDS in 2016.


So it may come as no surprise to anyone, but I am the youngest member of the Passaic County Dental Society.  I am also the youngest member on the Board of Trustees and third in line to be our next society president. You can say that I got an early start to getting involved.

Becoming a dentist never made my top ten list of what I wanted to be when I grew up. Even though I had a father who was a dentist, becoming a ballerina or a baker seemed much more appealing to me.  As the years passed, I did some maturing, reached high school and realized medicine was where my future was headed. I studied hard, got good grades, got accepted to Georgetown University and started college as a biology major. Throughout college, various family and friends would hint at the possibility of applying to dental school. I would usually just brush it off until one of my father’s dental school classmates sat me down at a summer bar-b-que and told me to apply to medical school but to also apply to just one dental school and then make my decision. That conversation ended up changing my life and future career path. I took his advice, took the DATs, applied to dental school on a whim and got accepted to UMDNJ.  Hello dentistry! Those four years in dental school were the best and worst years of my life, however as they say, at the end of every dark tunnel is a white light. Graduation day, May 16, 2010, was the happiest day of my life, not only because I felt lucky to have found a profession that I truly loved and passionate about. It was also the happiest day of my father’s life, because he finally found his exit strategy.

Even before the ink had dried on my diploma, my father talked about joining organized dentistry and the importance of me getting involved and giving back to the profession. My first year out of dental school I attended every Passaic County Dental Society meeting and the next year joined the Board of Trustees, alongside my father; the year after that I became an officer. As you can see, it did not take much time or effort to suck me in.

So far, my experience with PCDS has been great. I was warmly welcomed by my fellow colleagues. I have made valuable friendships and been exposed to many different aspects of the dental world. I have formed bonds and mentorships with clinicians thirty years my senior. More importantly, I have found a forum where there is no stupid question, there is no judgment, and members are there to mutually support each other. Not only that, they are there to share their stories and ideas:  What worked for them, and what didn’t work so much.

We, PCDS, are known to have one of the most culturally diverse societies and one of the nicest. We also have many more women than any other society in New Jersey. Our meetings and not cliquish, our members are all approachable and inviting and there is always someone to greet you. There really is the sense of camaraderie and family at every meeting. More often than not, the conversations are mostly surrounded around catching family, kids, health, and sports updates.

We also cannot forget what organized dentistry has done and continues to do for us as a profession.

We have constant support and resources from a group of people who advocate for our rights and best interests as dentists. As an NJDA member, I can call the NJDA headquarters at any time, pertaining to any issue I may be having in the office. These include legal issues and/or questions, state board, advertising, laws governing hygienists, HIPAA, OSHA, insurance issues, and many many more. These people have all, for the most part, been involved in dentistry their entire career and are here to provide us with advice and know-how which, in the long run, saves you time, money, and most importantly, aggravation. All you have to do is call and they actually call you back! I have actually done this myself a few times and I have always received a pleasant return call.

The bottom line is I honestly do not understand how anyone in this present environment can afford to practice without the backing of organized dentistry. Yes – the economy has changed; yes – practices are slower; and yes, patients have become more demanding. However, these are all the more reasons to stick together as peers, as a profession, and ride out the storm together. There will always be something that could be better, that could be changed, but I am happy to be part of an organization that embraces change and engages conversation for a better tomorrow for you and me.

About the Author

Dena Constandelis, DMD, joined her father, Theodore Constandelis, DDS, in general practice in 2011.  Their practice, Constandelis Dental Family and Aesthetic Dentistry, has been located in for more than 30 years.  In addition to being involved in organized dentistry, when she finds the time, Dr. Dena enjoys reading, trying new restaurants and running.

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